PAGE 1 Cancer prevention peer education with hard-to-reach communities A practice manual
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Cancer preventionpeer education
with hard-to-reachcommunities
A practice manual
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‘In the refugee camps back home we don’t have to do tests. Here we have to do
these tests. I told them in this country we have to follow
the rules. You should do the test to prevent things. When we are getting them, they are
scared of the vaccine and Pap test. Some don’t want
to do it. I tell them it is special protections for women.’
‘It’s not about the vouchers and it’s not about the job. We became peer educators from
our hearts.’
‘What I learned that day were things I never knew about, and I’ve been here for 20 years! And my community is willing to learn too. It’s
important for my community, especially for the next
generation, to improve our health.’
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‘This project is good because other projects give women health information and then
go away. This peer education is much better because after
the session we can follow them up and help the people. It is more effective this way.’
‘Because we have this knowledge now, I keep
sharing what I’ve learned with those who have no knowledge about these things. I believe this is very useful for women
and young people in my community.’
‘I am an expert in my community now; women
come to me to find out where to go for Pap test.’
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AcknowledgementsWe wish to thank the peer educators who have participated in the Cervical Cancer Prevention Peer Education program since its inception in 2013. These included peer educators from the local government areas of Wyndham, Hobsons Bay, Maroondah and Greater Geelong. Their work and commitment to the program has ensured a vast array of positive health outcomes, especially improved cancer screening participation and HPV immunisation rates among their families, friends and communities.
Thanks to our program partners: New Hope Foundation (Werribee), Migrant Information Centre (Eastern Melbourne) and Diversitat Migrant Resource Centre. Thanks also to ISIS Primary Care in Wyndham and Hobsons Bay, Eastern Access Community Health and Barwon Community Health Service; in particular, to the community nurse cervical screening providers and immunisation providers who worked with our peer educators to support their activities in the community.
Our sincere thanks to Lucy Forwood, our very committed and passionate Community Programs Coordinator, PapScreen Victoria, who developed the program and took it from its early pilot stage to the optimal level that it is currently achieving. This manual is testament to Lucy’s unflagging work over the years to improve the cancer screening participation rates of some of the most marginalised groups in Victoria.
Thank you to Heather O’Donnell, the HPV Vaccine Program Coordinator, for her support and contribution to the three peer education pilot projects.
Thank you to Hiranthi Perera, Program Manager, PapScreen Victoria, for her support on aspects of planning, implementing and evaluating the Cervical Cancer Prevention Peer Education program.
Special thanks goes to Chiedza Malunga who during the early stages of the program, while representing the Centre for Ethnicity and Health, provided Lucy with invaluable ideas and advice on how to establish a peer education initiative with newly arrived communities.
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Contents
About this manual 6What’s in this manual? 6Who is this manual for? 6Why would I use this manual? 6Why has this manual been developed? 7
The fundamentals 8A definition of peer education 8The reasons why peer education works 9A definition of hard-to-reach 10
Underpinning principles and practices 11Ready set go … not quite 11Health equity principles 12Health promotion practice 12Community development principles 13Culturally competent planning and practice 13Gender-specific practice 14
Peer education flow chart 16
The steps at a glance 17
Planning 19Step 1 Build your case 20Step 2 Scope opportunities and prioritise 21Step 3 Seek more information and develop partnerships 22Step 4 Prepare a logic model 24
Recruiting 26Step 5 Recruit peer educators 27
Training 29Step 6 Develop materials and resources 30Step 7 Plan the training day 31Step 8 Train peer educators 32Step 9 Conduct a service familiarisation visit with peer educators 36
Peer educators’ delivery 37Step 10 Allow peer educators to do their work 38Step 11 Provide extra support for peer educators as needed 38
Evaluating 39Step 12 Methods of data collection 40Step 13 Hold the evaluation meetings 42Step 14 Write a final report 44
Resourcing requirements 45
References 46
Appendices 47
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About this manual
What’s in this manual?
Welcome! Are you looking for a really valuable tool for your cancer prevention efforts? Ever wondered if peer education could be the answer and how to incorporate the approach into your work?
In this manual, you’ll find all the ingredients for conducting effective cancer prevention peer education with hard-to-reach communities in Victoria. The ingredients are:
•• definitions of ‘peer education’ and ‘hard-to-reach’
•• underpinning principles and practices for appropriate peer education with hard-to-reach communities
•• ‘who’s who’ of cancer prevention peer education
•• practical steps for conducting peer education with hard-to-reach communities – from planning and recruitment to training and evaluation
•• tips, checklists, examples and testimonials based on running successful cancer prevention peer education with hard-to-reach Victorian communities (these will provide even more hands-on guidance to your work)
•• references to additional resources that can help you along the way, and
•• time and resourcing requirements for the work to occur, so you’ll know what’s needed from start to end.
Who is this manual for?
This manual is designed for those working in cancer prevention, health promotion or community development, in particular those working on screening or immunisation programs.
Why would I use this manual?
If you’re interested in adding peer education to your cancer prevention work, then reading this manual will help to assess the feasibility in doing so.
Once you’ve decided that peer education is an important approach, then reading this manual will help to ‘build your case’ to others. These could be managers in your organisation or external partners who are needed to support the work once it gets going.
Once you’ve got the green light to do cancer prevention peer education, by following this manual as precisely as you can ensures successful planning, implementation and evaluation of your work.
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Why has this manual been developed?
Cancer Council Victoria has a long history of providing cancer prevention education in various languages to culturally diverse communities. We have a team of trained Bilingual Health Facilitators in a range of languages who spread the word and promote our prevention messages to existing community groups.
Since 2013, Cancer Council Victoria has piloted, implemented and evaluated a Cervical Cancer Prevention Peer Education program with the newly arrived Karen and Afghani communities of women in Victoria. The communities referred to in this document are the Karen women, who are exiles from Burma and (with their families) have recently arrived in high numbers in Melbourne’s west and east, and women from the Afghani community, who have settled in the Geelong area over the last four to five years.
Overall, the program demonstrated to Cancer Council Victoria the following impacts:
•• increased knowledge among peer educators of the benefits of cancer prevention
•• increased skills and confidence among peer educators to share cancer prevention messages with family and community members
•• improved (and enduring) linkages between peer educators and service providers of cancer screening programs
•• increased screening/immunisation participation among peer educators and others in their communities, and
•• sustained cancer prevention messaging by peer educators to others in their communities, months after we trained them as peer educators.
This last point also proved to Cancer Council Victoria the sustainability of peer education as a tool for prevention, since peer educators kept on messaging to their communities well beyond the main phase of our contact with them.
Cancer Council Victoria has developed this manual so that others within the organisation and, more broadly, in Victoria’s cancer prevention sector, can experience the benefits of cancer prevention peer education with hard-to-reach communities; and so that together we can continue to work towards reducing the impacts of cancer on all Victorians through prevention and early detection.
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The fundamentals
A definition of peer education
For the purposes of this manual, peer education is about community members learning about cancer prevention from their peers and as peers. It occurs between those who are seen as equals by each other in a specific context – the context of their community – and it takes place in everyday community settings such as the places where people gather (social groups, churches or schools) or in homes.
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A peer education approach has a strong and long-standing international evidence base in public health that goes back several decades (AVIL, 2006). For example, as early as the 1960s, programs have been in place in the US and Western Europe for former heroin injectors to provide targeted outreach to young people using illegal drugs. In 1999, UNAIDS documented the approach in the context of HIV/AIDS prevention (UNAIDS, 1999). Peer education has been widely adopted by those working on other communicable diseases, such as hepatitis C. It’s also been used by those working on other complex social problems with health impacts, like problematic gambling or violence.
The reasons why peer education works
The literature on peer education tells us why the approach is such an effective addition to our existing suite of strategies for tackling public health and social problems. Apart from having great reach into communities in a way that mainstream health educators often do not, the main reason is that peer educators are highly successful in producing behaviour changes that are desired as part of preventing or harm minimising the problem being addressed (Drummond et al., n.d.; AVIL, 2006).
Why does peer education work?
•• Peer educators know which health messages are more likely to resonate with (and be most acceptable to) others who are just like them, and how best to get these messages across. They are also sensitive to the types of non-verbal communication that exist within their communities.
•• Peer educators are perceived as a close, credible and trustworthy source of information, much more than mainstream health educators who can appear to be ‘distant’.
•• Information that is given peer-to-peer is more likely to be accepted by the community than if communicated by someone external or ‘outside’.
•• In the process of being trained and supported, peer educators gain ownership for action on the problem being looked at; and they, in turn, can empower others like them to do the same.
•• Peer educators can model the behaviour that is desired; they become credible role models in the eyes of those in their communities.
•• Over time, the influence of peer educators on individual behaviour change can actually contribute to deeper shifts in social norms within their communities, so that more individuals want to behave in the desired way.
Peer education in cancer prevention means working with members of a particular community so that they can generate positive changes ‘in community’ and peer-to-peer. These changes can occur at the individual level, through influencing knowledge, attitudes, beliefs or behaviours, or more broadly, by modifying their community’s norms about cancer prevention.
‘I continue to speak about the information especially if I’m asked. Some people
now come to me specifically with questions I can answer for them. And I can contact Cancer Council Victoria to
keep up to date.’ Karen Peer Educator
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A definition of hard-to-reach
For the purposes of this manual, hard-to-reach communities are communities in Victoria that experience marginalisation, discrimination or disadvantage – whether through unfair historical or contemporary social and economic factors – and that therefore have fewer opportunities to access resources for health than those in the mainstream community. Resources for health include information and messages about cancer prevention.
For Cancer Council Victoria, the hard-to-reach includes culturally and linguistically diverse communities, newly arrived or emerging communities, people who identify as Aboriginal and Torres Strait Islander, people experiencing socio-economic disadvantage, people living with a disability, and Victorian rural and regional communities, to name a few. Cancer Council Victoria knows that for these groups, poor cancer outcomes are a reality. As such, it is up to the cancer prevention sector and its partners to redress such inequality with tailored strategies that are appealing to these communities and effective for them too – such as peer education – so that no Victorians miss out on the benefits of prevention and early detection. (More on equity can be found in Underpinning principles and practices on page 11.)
For the purpose of this manual, the focus is on newly arrived or emerging communities as a hard-to-reach group, since this is where Cancer Council Victoria’s peer education experience and evidence lie. Of course, we believe that the fundamentals, principles, practices and steps for peer education contained in this manual are transferrable to cancer prevention with the other hard-to-reach groups described above. It’s the approach and the model that matter.
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Underpinning principles and
practices
Ready set go … not quite
Before cancer prevention peer education can happen and its positive impacts felt throughout Victoria’s hard-to-reach communities, peer educators must first be empowered in their knowledge of cancer prevention, their relationships with local health providers, and their skills and confidence to share what they know with their peers.
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For this to be done well, however, you first need to understand the principles and practices that underpin cancer prevention peer education. Spend time familiarising yourself with the following underpinning principles and practices of cancer prevention peer education before you embark on the steps for doing the work.
These are:
•• health equity principles
•• health promotion practice
•• community development principles
•• culturally competent planning and practice, and
•• gender-specific practice.
Health equity principles
Addressing health inequity is what drives us to undertake specific and tailored cancer prevention work with hard-to-reach communities.
Health inequity exists when any group in our population experiences poorer health outcomes compared to other groups, and when those outcomes are the result of social, economic or demographic factors that are unfair and avoidable or modifiable (Solar and Irwin, 2010). In Victoria, a common feature of communities with poorer health outcomes (including poorer cancer outcomes) is their marginalisation, discrimination or disadvantage relative to the rest of the population – factors that give these communities fewer opportunities to access resources for health compared to others in the general population.
For those of us in cancer prevention, it’s our job to make extra efforts to reach groups that are currently sidelined from the mainstream (and consequently hard-to-reach) so that they can have the same opportunities as everyone else to be healthy. This is the concept of health equity, and it revolves around fairness.
Health promotion practice
Health promotion practice is a solid framework for action to locate peer education as one of several possible strategies for achieving greater health equity.
Health promotion is the process of enabling communities to increase control over their own health and thereby improve it, with health understood as a complete state of physical, mental and social wellbeing and not only the absence of disease or infirmity. A fundamental principle of health promotion is empowering communities to take the future of their health into their own hands, with a focus on communities that are especially disempowered. In this way, realising health equity is central to any health promotion action.
Within health promotion practice, there are several different types of actions that can be taken to empower communities; and integrated health promotion requires us to undertake a mix of these actions for best results. The actions are shown in the following diagram.
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Health promotion actions and capacity building strategies
Individual focus Population focus
Screening
Immunisation
Risk assessment
Health education
Skill development
Social marketing
Health information
Community action for social change
Advocacy
Policy
Economic or regulatory activity
Legislation
Build capacity to undertake the above actions through:Organisational developmentWorkforce developmentPartnershipsLeadershipResources Research and evaluation
Adapted from Integrated health promotion: A practice guide for service providers, Victorian Government Department of Human Services
Peer education can be thought of as an alternative to traditional forms of health education: one that is particularly suited to hard-to-reach communities. In keeping with internationally sound health promotion practice, peer education should be done in conjunction with other types of health promotion actions, such as organisational development to strengthen support for the approach, community action for social change, or evaluation to capture impacts and share learnings. As you will see, this is exactly what cancer prevention peer education does!
Community development principles
Community development principles are an important platform for cancer prevention peer education in that they ensure the work is of the highest quality possible.
Community development, in the context of health promotion practice, involves the process of working with communities (not ‘on’ or ‘for’ them) to facilitate their awareness of the factors and conditions that affect their health and, ultimately, to equip them with the knowledge, skills and confidence they need to take action on or improve upon those conditions (Hawe et al., 1990).
Culturally competent planning and practice
Cultural competence (also known as cultural responsiveness, awareness or sensitivity) means purposefully aiming to foster constructive interactions with hard-to-reach communities because our lens on the world is different from theirs and vice versa (ECCV, 2006). This involves becoming culturally aware of hard-to-reach communities, gaining cultural knowledge about them, and achieving cultural skills for our interactions. Importantly, it also involves the ability to challenge our own assumptions, values and beliefs, and to see that we all view the world through different lenses.
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There are some key characteristics of a culturally competent practitioner (ECCV, 2006). These people are likely to possess:
•• strong knowledge of how their own culture shapes attitudes, perceptions and behaviours
•• a valuing of diversity and a willingness to learn about others from backgrounds different to their own
•• specific knowledge about the language, customs and values of others from backgrounds different to their own
•• skills to feel comfortable and communicate effectively with others from backgrounds different to their own, and
•• an awareness of the limited value of cultural stereotypes.
You’ll see these cultural competence characteristics at play in many of the steps for peer education contained in this manual.
Gender-specific practice
Cancer prevention peer education means approaching hard-to-reach communities about a specific topic and working with them to improve knowledge and understandings and increase skills and confidence. Just as in mainstream culture, gender roles and norms in hard-to-reach communities will require you to be gender-specific in your practice.
Remember, cancer prevention peer education is designed for community members learning about cancer and its prevention from peers and as peers. In the case of cervical, breast and bowel cancer, this includes learning about screening or immunisation programs that are part of the prevention landscape for these cancers. As such, the eligibility requirements for participation in Australia’s screening or immunisation programs will necessarily dictate the gender of peer educators for cancer prevention.
•• Cervical cancer prevention. Peer educators are most likely to be women who fall within the eligible age groups for cervical screening or who can speak to mothers about their daughters who may fall within the eligible age groups for immunisation. More recently, the HPV immunisation program has opened to include adolescent males, since the vaccine prevents other types of cancers associated with the human papillomavirus (or HPV) that also affect males. Given women’s caregiving roles in many communities, women are the most suitable peer educators for educating their communities regarding HPV-related cancers more broadly.
•• Breast cancer prevention. Peer educators are most likely to be women who are within the eligible age groups.
•• Bowel cancer prevention. Peer educators can be men or women who are within the eligible age groups.
What does gender-specific practice look like in these scenarios?
When peer educators are predominately (or only) women, gender-specific practice means ensuring that all your planning responds to their needs so that the work you do with them is as accessible and appropriate as possible. You must gain insight into the gender roles and norms of the hard-to-reach communities you’re working with, and understand the lived experiences of women in these contexts. For example, schedule meeting times that are mindful of school drop-off or pick-up times or provide childcare for peer educators.
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The same applies when peer educators are of both genders: you don’t want to inadvertently exclude women’s participation as peer educators because of your lack of understanding of their gendered lived realities. It’s also important that you use your cultural competence to determine whether you can indeed mix female and male peer educators in the various meetings you’ll be convening. Based on cultural sensitivities around health and illness, perhaps your practice may need to accommodate female and male bowel cancer peer education separately.
As with cultural competence, you’ll see gender-specific practice at work throughout many of the steps contained in this manual on cancer prevention peer education.
A continuum for approaches to gender in health promotion showing where gender-specific practice sits
Source: Greaves L, Pederson A, Poole N (2015)
Gender unequal
Gender blind
Gender sensitive
Gender specific
Gender transformative
EXPLOIT ACCOMMODATE TRANSFORM
FEATURES
GENDER INEQUALITY
GENDER EQUITY
Perpetuates gender inequalities
Ignores gender norms
Acknowledges but does not address gender inequalities
Acknowledges gender norms and considers women’s and men’s specific needs
Addresses the causes of gender-based health inequalities and works to transform harmful gender roles norms and relations
APPROACHES
Peer education flow chart
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Program coordinator
Plans, recruits, trains and supports peer educators, develops partnerships and evaluates the program
Colleague support
Supports the development of materials and resources, co-facilitates training and evaluation meetings
Partner agencies
Specialist agency assists with recruitment
Cancer screening local service providers
Peer educators
In pairs, deliver peer-to-peer sessions ‘in community’
Support community members to implement behaviour change
Peer educators’ family and friends
Empowered to take the future of their health into their own hands
Program coordinator, colleague support, partner agency, and peer educators
Peer educators
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The steps at a glance
The following sections of this manual contain 14 steps that show how cancer prevention peer education is done. The steps build on one another and should be completed sequentially.
Planning
Step 1 Build your case
Step 2 Scope opportunities and prioritise
Step 3 Seek more information and develop partnerships
Step 4 Prepare a logic model
Recruiting
Step 5 Recruit peer educators
Training
Step 6 Develop materials and resources
Step 7 Plan the training day
Step 8 Train peer educators
Step 9 Conduct a service familiarisation visit with peer educators
Peer educators’ delivery
Step 10 Allow peer educators to do their work
Step 11 Provide extra support for peer educators as needed
Evaluating
Step 12 Methods of data collection
Step 13 Hold the evaluation meetings
Step 14 Write a final report
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Cancer prevention peer education initiative – GANNT chart
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
Month 10
Planning* (Step 1 to Step 4)
Recruitment (Step 5)
Materials and resources (Step 6)
Training day (Step 7 and Step 8)
Service familiarisation visit (Step 9)
Peer-to-peer sessions (Step 10)
Support as needed (Step 11)
Data collection methods (Step 12)
Evaluation meetings (Step 13)
Report write up (Step 14)
* Planning is subject to stakeholders’ availability.
The Gantt chart is shown to indicate the months in which the project steps occur. All up, you can expect your cancer prevention peer education initiative to unfold over a period of around 10 months.
Planning
A thorough planning process will ensure that your cancer prevention peer education gets off to a solid start.
There are four steps involved. •• Build your case for cancer prevention peer education
•• Scope opportunities to do the work and prioritise
•• Seek more information and develop partnerships
•• Prepare a logic model
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Step 1 Build your case
The first step in planning for cancer prevention peer education with a hard-to-reach community is to make sure you have the support of your organisation to undertake such work. If your organisation is not familiar with the peer education approach and its benefits, then you’ll need to build a case. Within the health promotion framework discussed previously, this is known as organisational development, and it’s an important part of building capacity for the work that you do.
Use the information contained throughout this manual to build a case for the work:
•• Refer to The fundamentals on page 8, which explains peer education’s long-standing evidence base in public health and the reasons why it works with hard-to-reach communities.
•• Refer to Underpinning principles and practices on page 11, which states that any health promotion action should be about improving health equity and that a really great way to do this is through peer education.
•• You might also wish to follow up the references that are cited in these sections to deepen your understanding of the content that is covered in them.
While the benefits of peer education for hard-to-reach communities are important for you to note, it’s equally as important to emphasise the sustainable outcomes for any organisation that’s committed to it. This is because peer educators can be expected to keep messaging long after the work with an organisation has ended. This has been the case with Cancer Council Victoria’s experience in cervical cancer prevention peer education with Karen and Afghani women, with desired screening behaviour continuing to occur over time.
•• See the two following graphs and the information in Resourcing requirements on page 45.
•• Contact the Cancer Council if you want to find out more about the impacts and sustainability of cancer prevention peer education.
•• Use all this information as evidence.
Effectiveness of peer education on sustained messaging and screening behaviour, Cervical Cancer Prevention Peer Education program 2013 and 2014
0
30
60
90
120
150
During peer-to-peer sessions
6 months later Total
Cervical cancer screening information shared by Karen peer educators (number of people)
Melbourne’s east (2014)
Melbourne’s west (2013)
7277
66 69
138146
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In your mind, make clear links between cancer prevention peer education, health equity and your organisation’s strategic directions, and how introducing a peer education initiative will contribute to achieving the key result areas of your organisation’s overall strategy.
When you meet with your managers or organisational leaders:
•• speak clearly and confidently to what you’ve found out
•• let your audience know there’s an evidence-informed manual to guide you every step of the way, and
•• bring this manual along with you!
Step 2 Scope opportunities and prioritise
As someone who works in cancer prevention, you are likely to have ready access to Victorian cancer data. This data can tell you a lot about specific areas where there are lower screening participation or higher cancer incidence rates. Your organisation will most likely have already highlighted some of these areas for its cancer prevention focus.
Thinking about one or two of Victoria’s hard-to-reach communities that you’d like to work with, obtain local statistical information that shows exactly where they live in Victoria. There are many existing data sets accessible to the public that will provide you with this information.
•• Settlement Reporting Facility: www.immi.gov.au/settlement
•• Settlement Arrivals and Needs Information: www.dss.gov.au/our-responsibilities/settlement-and-multicultural-affairs/
•• HealthInfoNet (Aboriginal and Torres Strait Islander health): www.healthinfonet.ecu.edu.au
•• Australian Bureau of Statistics (for socio-economic information): www.abs.gov.au/census
0
10
20
30
40
50
Melbourne’s east (2014)
Melbourne’s west (2013)
1 month after peer-to-peersessions
6 months later Total
Cervical cancer screening appointments made as a result of Karen peer education (number of people)
16
20
25
13
41
33
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If your organisation has a research unit it may be able to point you in the right direction to source what you need.
Once you have a demographic profile of your communities of interest, you’ll be in a position to do some ‘cross-matching’ with your cancer data.
•• Select areas where there are high numbers of your communities of interest and where screening participation rates could be improved.
•• Consider these areas carefully, and choose particular areas for a peer education initiative on one cancer prevention topic with one hard-to-reach community.
•• There might be strategic things to factor into your decision making; for instance, if your organisation has a commitment to focusing on one of your areas, or if there are external factors that might lead you to deciding on one area.
Step 3 Seek more information and develop partnerships
You are now in a position where you can find out more about the community you’ve selected to work with, now what is needed is local knowledge.
•• Do a service map of the area and find out about the agencies that support your community of interest. For newly arrived communities, for example, these are the local migrant resource centres or other agencies providing ethno-specific services.
•• Contact the most relevant agency and arrange a meeting where you can find out more about your community of interest: what their lives are like, the way they see the world, their beliefs about health and illness (especially cancer), their engagement with local services, where they meet, and so on.
•• Use this meeting to explain cancer prevention peer education, the work you’re hoping to do, and the possibility for this agency to be involved in a support role, especially when it comes to recruiting peer educators.
•• Find out where the local community health or screening provider is located. Make contact with them and invite them to be involved in a support role. They will play a part when it comes to familiarising peer educators with local services.
•• Bring this manual along with you to all these meetings.
Take all of this information back to the office and spend time becoming as culturally aware of your community of interest as you can. You’re aiming to build the knowledge you’ve gained thus far about your community of interest. By doing this, you’ll have important tools for fostering constructive interactions with your community of interest when you meet.
•• Multicultural Centre for Women’s Health has training on gendered cultural awareness, and can provide consultation or point you to useful resources: mcwh.com.au/common-threads-training.php
•• Centre for Ethnicity and Health has resources and training on cultural competence: www.ceh.org.au/a-framework-foral-competence
‘When Lucy told me about peer education, I was interested. I saw
that it could be helpful to the Karen women. Our people are private and no one talks about cancer. It exists but we don’t talk about it. I thought it would be perfect timing to begin. I didn’t think it was important until
the opportunity came up.’ Karen Community Worker,
Werribee
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Below is an excerpt from a piece prepared by the Cancer Council Victoria worker who ran the Cervical Cancer Prevention Peer Education program with Karen women. It shows her desire to be as culturally competent as she could to prepare for her work, and how this translated into valuable insights about the lens through which Karen people see the world.
Who are the Karen?The Karen people are an ethnic minority group who originate from Burma (or Myanmar) and whose community is continuing to grow in Victoria, particularly in the Wyndham and Hobsons Bay local government areas, and more recently in the eastern suburbs.
The Karen people who have come to Australia as humanitarian refugees have spent their entire lives living in refugee camps on the Thai-Burma border. They do not like to be associated with anything ‘Burmese’ as they were exiled from Burma by the Burmese. I learned very early on to refer to them as refugees from Burma, not Burmese refugees. I have been careful all along to never refer to them as Burmese as this is a great insult.
During my research about the Karen, I learned that the Karen people here are very religious (mostly of the Christian faiths) and by mainstream Australian standards are a conservative group. They are highly organised and value family over and above everything. I learned that the Karen people are a very private, closed and self-contained community, with very few formal connections with health and community services. Their preferred language is Karen.
I was advised early on that it was important to attend functions that I was invited to. I was invited to a wrist tying ceremony. Wrist tying is part of the Karen culture, a tradition from generation to generation. Once a year, the Karen people in Victoria gather together and the elders tie white thread to wrists and give blessings, while there is music, dancing and food. Each piece of thread represents a symbol of good luck. The ceremony was in a huge auditorium in Werribee with hundreds of people. I was one of the few non-Karen people there.
Life in the refugee camps … well, there is only basic education at the primary school level. Common health problems in the refugee camps include malnutrition, parasitic infections, hepatitis B, tuberculosis and malaria. Preventative health is non-existent.
Refugees are not allowed out of the refugee camps and cannot work; however, they serve on camp committees, which are the administrative and management bodies of the camps. Consequently, I found the Karen women I worked with to be incredibly well organised and supportive of one another. Their motivation is very much for the good of their community, not themselves as individuals.
Karen Wrist Tying Ceremony
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Step 4 Prepare a logic model
A logic model is a clear visual representation of the cancer prevention peer education initiative you’re about to put in place. It shows the inputs, activities, outputs and desired impacts of your initiative. It is also a handy device to guide the evaluation of your initiative.
A good logic model has four essential components
•• Inputs are the resources that are available for your cancer prevention peer education initiative. They include things like the organisational backing and management support that you’ve secured for the work, and your time as the worker.
•• Activities are what you do with the inputs. They include things like engaging with the agencies and service providers in the local area to play a support role in your initiative. They also include things like recruiting peer educators from hard-to-reach communities and training them.
•• Outputs are tangible products arising from the activities. They include things like hosting recruitment sessions with prospective peer educators, or delivering a training day, or completing a service familiarisation visit.
•• Impacts are the changes sought through the activities and outputs. These include (and are not limited to): – increased knowledge among peer educators of the benefits of cancer prevention– increased skills and confidence among peer educators to share cancer prevention messages
with family and community members– improved (and enduring) linkages between peer educators and service providers of cancer
screening programs– increased screening or immunisation participation among peer educators and others in their
communities, and– sustained cancer prevention messaging by peer educators to others in their communities,
months after they were trained as peer educators.
When it comes time to evaluating your initiative, you’ll use the outputs in your logic model to guide a process evaluation, and the desired changes in your logic model to guide an impact evaluation. More on these later!
A good logic model should also show the goal and objectives of your initiative
•• A sound health promotion goal is ‘big picture’. It looks to the long-term gains in health equity that your initiative is part of.
•• Objectives are more specific to your initiative in that they restate the goal in concrete terms, or what it is, exactly, that your work will contribute to in relation to the goal.
How do you bring all these elements together into a logic model for your cancer prevention peer education initiative? See the next page to give you an idea of what’s involved.
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Program logic
GOAL: To improve the cancer outcomes of people from newly arrived communities in Victoria
OBJECTIVES: To build the health literacy* of Karen women in Melbourne’s west in relation to cervical and other HPV-related cancers
To empower Karen women as peer educators of cervical and other HPV-related cancers and their prevention
To generate desired behaviour changes in the Karen community in relation to cervical screening and participation in the HPV immunisation program
To enhance relationships between the Karen community, local service providers and Cancer Council Victoria
Inputs
Evidence of effectiveness
Principles and practices of peer education e.g. culturally competent planning and practice
Step-by-step manual
Management support or organisational backing
Staffing
Resources
Activities
Engage supporting local agencies and service providers
Develop roles and responsibilities, expression of interest form
Recruit peer educators
Develop materials and resources for peer educators
Train and support peer educators
Conduct service familiarisation visit
Plan for evaluation
Undertake process and impact evaluation
Outputs
Translated roles and responsibilities, expression of interest form
1 x recruitment session
10–14 community women recruited
Culturally and linguistically appropriate materials and resources
Translated written evaluation form
1 x training day
1 x service familiarisation visit
Delivery of sessions ‘in community’ by peer educators as per roles and responsibilities
Evaluation report
Desired immediate changes
Increased knowledge among peer educators of cervical and other HPV-related cancers and the benefits of prevention
Increased skills and confidence among peer educators to share cancer prevention messages ‘in community’
Improved linkages between peer educators and local service providers and Cancer Council Victoria
Increased screening or HPV immunisation rates among peer educators and community members receiving peer-to-peer education
Desired medium-term changes
Sustained messaging by peer educators 6 months after the training day
Desired longer-term change
Enduring linkages between peer educators and local service providers and Cancer Council Victoria
Shifts in Karen community norms as more community members exhibit desired prevention behaviour
* Health literacy is the knowledge and skills needed to both understand and use health information.
Recruiting
You’re now ready to begin implementation, and that means recruiting between 10 and 14 peer educators for your cancer prevention peer education initiative. Cancer Council Victoria’s experience has shown that the best way to do this is to organise a community meet and greet.
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‘Lucy was very clear about what she wanted. We ended up having
two meetings, one on Friday afternoon and another on Saturday afternoon. I rang around to make sure women attended. If you want 10 peer educators, then aim for
40 or 50 to attend.’ Karen Community Worker,
Werribee
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Step 5 Recruit peer educators
You’ll first need to re-connect with the local agency that you’ve already had preliminary conversations with about their possible role in your initiative (Step 3 Seek more information and develop partnerships on page 22). Ask the agency to advise and assist you in connecting with your chosen community.
•• Work with the agency to firm up details about the recruitment session. Consider places where the community meet and days and times that suit them, even if on the weekend. You might need to make provision for more than one meeting depending on the local knowledge given to you.
•• Develop a simple one-page invitation in plain English, as shown in the example found on page 48.
•• Have the invitation translated and checked for accuracy and appropriateness. Use reputable translating services. Invest time into making the invitation visually appealing, again checking for its appropriateness to your community of interest.
•• Give the invitation to the local agency you’re working with for them to contact members of the community.
•• Arrange catering.
•• Book an appropriate interpreter from a reputable service and brief them fully about the meeting.
Prior to the date of the meet and greet, you’ll need to prepare the materials for the meeting. These are a running sheet, the roles and responsibilities of peer educators, and an expression of interest form for interested community members to complete.
•• Your running sheet should cover the following items, which you will then go through in order at the recruitment session. – An introduction of yourself and your organisation. – Basic information about the cancer topic you’re there to talk about.– Basic information about how this cancer can be prevented. Plus what these measures look like
and who’s eligible for them. – An explanation of why you need the help of people at the meeting to spread the message of
cancer prevention throughout their community, and an introduction to your peer education initiative. Let people hear the benefits of being involved for their community. These are the most important messages of your meeting, so make sure there’s enough time on your running sheet for these.
– The roles and responsibilities of peer educators. – The expression of interest form.
TIP
Gender-specific practice is central to everything you do. Finding an appropriate interpreter for all your interactions with the community of interest means considering whether a gender-specific interpreter is required.
‘I’m busy but thought it would be good to go along to the meeting. I found out what
was involved in the project, and a little about the cancer and how it could be prevented,
for example, through vaccination. I was interested! I filled in the application form!’
Karen Peer Educator
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•• The roles and responsibilities of peer educators is a one-page sheet that lists the expectations of peer educators who come on board, as shown in the example found on page 50 of this manual.
•• The expression of interest form is a simple sheet that asks specific information of those interested in becoming peer educators, as shown in the example found on page 49 of this manual.
Have the roles and responsibilities of peer educators and expression of interest form translated into the language of your community of interest prior to the meet and greet.
At the meeting, try and personally greet everyone who arrives and be as welcoming as you can. After all, they are giving up their time to come and hear what you have to say.
•• Stay on track with your running sheet and allow plenty of time for questions.
•• Be prepared to assist people in completing their expression of interest forms; involve the interpreter during this part of the meeting too.
•• Working with an interpreter can double the time it would normally take to run a meeting in your own language, so be sure to take this into account.
After the meeting, take the completed expression of interest forms back to the office and make your selection of 10 to 14 peer educators. Refresh your mind on the reasons why peer education works to assist in your selection (see The fundamentals on page 8). Look for educators that the community can connect with, peer-to-peer; and consider the eligibility requirements of cancer screening and immunisation programs.
The final task in this step is to communicate with everyone who completed an expression of interest form and notify them of the decision, successful or otherwise. It’s a good opportunity to inform those who were successful in their applications of the date, time and venue for the training day too, based on the information they gave you in the expression of interest forms.
TIP
Select people with a degree of shared lived experiences, such as a common migration or settlement story. This will help with the training day experience.
Peer educators recruited from the Western region
Training
There are four steps associated with training.
•• Develop materials and resources for peer educators
•• Plan the training day
•• Train peer educators
•• Conduct a service familiarisation visit
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PAGE 30
In completing the steps, your peer educators will have everything they need to educate others about the cancer prevention they’ve learned, ‘in community’ and peer-to-peer. This includes knowledge of the benefits of cancer prevention, the skills and confidence to share cancer prevention messages with family and community members, and relationships with local cancer screening service providers.
Step 6 Develop materials and resources
Peer educators require materials and resources to deliver their peer-to-peer sessions. You’ll need to produce all of these ahead of the training day so you can demonstrate how they are to be used and peer educators can practice using them before going into their communities.
•• Work with a cancer prevention colleague on the most up-to-date content for your peer educators.
•• Discuss the key messages that need to be communicated and write them in plain English.
•• Consider the perspective through which your community of interest views the world and adapt the messages accordingly.
•• Structure the content so it flows logically.
•• Make sure the content can be presented as easily in hard-copy format (e.g. presentation folders) or on a computer (as a PowerPoint presentation via a USB stick). Your peer educators will then have a choice of the format in which they prefer to have their materials and resources for their peer-to-peer sessions.
•• Develop associated handouts (e.g. flyers, fact sheets) by identifying key messages, writing in plain English, adapting to suit cultural context, and structuring for flow.
•• Have all these materials and resources translated and checked for accuracy and appropriateness by a reputable service.
There’s one other document to develop ahead of the training day: a written evaluation form for peer educators to complete at the end of their peer education sessions. This form is one of four methods of data collection for evaluating your initiative, explained later in this manual. The form is handed out on the training day, and it must be structured so that peer educators can record information needed for you to evaluate the initiative. You’ll need to have the written evaluation form translated ahead of the training day too.
Please see appendices for the written evaluation questions we gave to women as handouts during the peer education training.
‘The challenge was how to communicate key messages simply and respectfully. HPV is sexually transmitted, bottom line. It’s about vaccinating an adolescent who is pre sexual activity. So we used
language like, ‘The vaccine protects young people for when they are married.’ We were surprised when the women themselves, on training day, brought up the
topic of pre-marital sex. They opened the door for us to talk about that, and we went through it with them.’
Colleague Support Worker
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Step 7 Plan the training day
The first task in planning for the training day is to develop the training outline for a four to five hour session. At a minimum, your outline should cover the following activities, which should also be split over a lunch break.
Activity Who Suggested time
Welcome and introductions Co-facilitators and group 10 mins
Icebreaker and getting to know each other Everyone 10 mins
Exploring cancer prevention using scenarios Peer educators in 3 or 4 small groups; everyone as a group
40 mins
Roles and responsibilities Co-facilitators 10 mins
Demonstration of cancer prevention presentation
Co-facilitators model how peer educators will educate
40 mins
Lunch (provided) Everyone 30 mins
Presentation practice runs Peer educators in pairs 60 mins
Group discussion: how did you go? Co-facilitators and group 30 mins
Planning peer-to-peer sessions Peer educators 30 mins
Upcoming dates: service familiarisation visit and evaluation meetings
Co-facilitators 10 mins
Final words, thank you and close Co-facilitators 20 mins
One other thing to do to plan for the training day is to enlist a co-facilitator, preferably a cancer prevention colleague, and brief them about their role. A pivotal part of the training day is the demonstration of the cancer prevention presentation to the group, and this must be done with a co-facilitator so you can both model how the peer educators themselves will do their peer-to-peer sessions ‘in community’. It’s a good idea to develop a detailed co-facilitators’ running sheet, based on the training outline above, that clearly shows who has responsibility for which part of the day.
‘Lucy explained what the project was trying to achieve. It was education; it was about the women learning. I had to understand that the project was about empowering the women to go into the community as peer
educators. I saw that it wasn’t about a content expert saying to the women, “I’m here to tell you”. This
wouldn’t have worked at all.’ Colleague Support Worker
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The final piece of planning is to arrange catering (ensuring food is culturally appropriate), childcare and confirm venue arrangements for the day. And you also must book an appropriate interpreter from a reputable service and brief them fully about the meeting.
Step 8 Train peer educators
Before you set off for the training day, complete the following checklist.
Checklist for the training day Tick
Training outline or detailed co-facilitators’ running sheet
Venue, catering and childcare confirmed
Interpreter confirmed
Handouts for the scenarios
Roles and responsibilities of peer educators
Materials and resources for peer educators
Lap top and projector (if required)
Whiteboard markers, butchers paper, name tags, pens, paper, camera
Vouchers to cover costs of peer-to-peer sessions
Written evaluation form
At the start of the training, try and personally greet everyone who arrives and be as welcoming as you can.
Then simply follow your training outline or detailed co-facilitators’ running sheet. Here’s a look at how the main activities will unfold: the icebreaker, scenarios, roles and responsibilities, demonstration of the presentation, presentation practice runs, discussion, planning, upcoming dates, and final words.
The icebreaker activity can be as simple as forming a line based on the year of arrival to Australia. This is something that peer educators can replicate when it comes to doing their peer-to-peer session ‘in community’ (as can all the activities that comprise the training day).
Scenarios are a great way for peer educators to open up and share their understandings, views, beliefs and fears in relation to what they’re learning about. That’s because scenarios are done in third person; they therefore create safety among members of the group to talk about what they think should happen without being judged.
TIP
Book the same interpreter throughout implementation of your initiative. It helps with continuity for peer educators and really makes a difference to their experience.
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Scenarios are also a really great way for the co-facilitators to gauge where members of the group are at in relation to the topic, and therefore what they have to work with when it comes to presenting the facts about cancer prevention a little later in the day. At this stage, however, it’s all about actively listening and not offering any information. It’s the stories and lived experiences that sit behind what is being said that are important for you to hear.
•• Ask peer educators to get into small groups of three or four and talk about the questions accompanying the scenarios.
•• After 20 minutes, ask small groups to report back to the larger group.
•• Ask the interpreter to help you whiteboard the main themes from the discussion. This will come in handy when you demonstrate the cancer prevention presentation to the group.
Below are the two scenarios that Cancer Council Victoria used for its Cervical Cancer Prevention Peer Education program with Karen women.
Cervical screening scenario
Tamla is a Karen woman who is a refugee from Burma. Tamla arrived in Melbourne with her family five years ago. She is 35 years old and is married.
Tamla and her husband have twins, a boy and a girl who are 13 years old. Tamla’s friend told her about something called Pap tests.
IN SMALL GROUPS TALK ABOUT 1. Should Tamla have a Pap test? 2. What makes it difficult for Tamla to go for a Pap test?
Vaccination scenario
Tamla’s two children have just started high school.
They have come home and given her cards. The cards are written in English The cards’ title is ‘Human papillomavirus (HPV) Immunisation Consent Card’.
Her children tell her it is about a needle that all the students are getting. Her children say she needs to sign the card to let them have the needle.
IN SMALL GROUPS TALK ABOUT 1. Should Tamla sign the card? 2. What makes it difficult for Tamla to sign the card?
It’s a good idea to go through the roles and responsibilities (see page 50) of peer educators once again on the training day, so everyone is clear about what’s expected of them. Allow time for questions that peer educators may have.
‘As co-facilitators, we’re simply listening, not
correcting. Later, in the presentation, you can offer
information in a general way that will give an
alternative to what’s been said, but for now it’s all
about listening.’ Colleague Support
Worker
‘For me as a facilitator the scenarios really help to understand what it’s like to be in their shoes, in a
country where everything is new, and from a place
in which experiences were so different. It levels us, it empties my assumptions
about those in the room so I can hear what they
are saying.’ Program Coordinator
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The demonstration of the cancer prevention presentation is next. This is when you and your co-facilitator present the information about cancer prevention that peer educators need to learn; it’s also when you as co-facilitators model exactly how the materials and resources that you’ve developed for peer educators are to be used by them during their sessions ‘in community’.
•• Provide peer educators with the materials and resources that you’ve developed. Make sure peer educators receive the materials and resources in the format they prefer: in hard copy (as a presentation folder) or as a PowerPoint presentation on a USB stick for a computer.
•• Explain that as peer educators they will be delivering the exact same presentation they are about to see you demonstrate.
•• Demonstrate the presentation to the group using good techniques: speak clearly, encourage questions from the group, and show them what it’s like to listen openly and respond to questions respectfully.
The presentation practice run follows after lunch. This is where paired peer educators practice the cancer prevention presentation you’ve just demonstrated and that they, in turn, will be delivering to members of their community once they are trained.
•• Ask peer educators to pair up. Explain that these will be the pairings that go into the community to deliver peer-to-peer sessions. For those with good English language proficiency, encourage pairings with someone who has less.
•• Instruct paired peer educators to practice the presentation of the materials and resources in turn, exactly as it’s been demonstrated by you. When one practices, the other pretends to be a member of the community, and vice versa.
•• Ask the person role-playing the ‘community member’ to pose questions to the peer educator exactly as a community member might.
•• Walk around the room as people are practicing, observing how they are going.
‘The scenarios opened up a safe space for the women to share their stories of life on the camps particularly regarding
inadequate health care. Some had stories of damaging health care involving untrained practitioners or experimental
vaccinations and awful side effects. That was the lens through which they were viewing the HPV consent cards and the Pap test. All of them said that Tamla shouldn’t sign the card. Many
of them were nervous about Tamla having such a private procedure as the Pap test. The general tone was distrust and
fear of the medical system in Burma … and here too.’ Program Coordinator
‘The most critical part of the practice is the questions they come up with. “Aren’t vaccines dangerous?” “Will the Pap test hurt?” If they don’t have the answers to these questions before they leave, they won’t be able to answer them when the
sessions are really happening.’ Program Coordinator
Peer educators practicing delivery
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When the pairs are all through their presentation practice runs, bring the group together for a discussion on how they went.
•• Invite peer educators to share the questions they posed to one another during the course of the presentation practice run.
•• As co-facilitators, once again show peer educators how to respond to these questions respectfully.
•• Let peer educators know that while you’ve covered their questions today, there might be some that are new when they deliver their session ‘in community’. They can always follow up those questions with you to find out the answer for their community. Give them your contact details once more.
The planning activity provides time for paired peer educators to organise their upcoming peer-to-peer sessions: the when, where, who and how.
•• Ask paired peer educators to decide on when they’ll have their sessions, where the sessions will be held, who will be invited, and how they’re going to invite them.
•• Remind peer educators that as pairs they need to deliver two sessions with a minimum of 10 people in each session.
•• Remind peer educators that their presentation includes information about a cancer prevention program with eligibility requirements. They’ll have to keep those eligibility requirements in mind when thinking about who they’ll invite to their sessions.
•• Ask each pair to report back to the whole group about their planning decisions.
•• Hand out the written evaluation forms, and explain what needs to be recorded. Let them know that their completed forms will need to be returned at an evaluation meeting, the date for which will be set before the end of the training day. Be mindful that there could be varying degrees of literacy in the group: provide options to speak to the questions on the form when the evaluation meeting comes around instead.
•• Hand out the vouchers to cover the costs for their peer-to-peer sessions for food, transport, etc. See Resourcing requirements on page 45.
The final part of the training day involves setting two important upcoming dates: the service familiarisation visit and an evaluation meeting (the first of two such meetings) where peer educators will bring back their completed written evaluation forms.
•• Go around the room and confirm with each pair of peer educators when they will have completed their two sessions ‘in community’.
•• Arrive at consensus on the date of the service familiarisation visit, which should be done as soon as practicable. Peer educators will be required to assemble there on the agreed day and at the agreed time.
•• Arrive at consensus on the date and venue for the evaluation meeting.
Before your final words of thanks, be sure that any remaining questions your peer educators might have are fully answered. Wrap up the day and close the meeting.
‘The role-play activity forces them to not only deliver the information but really understand it
too, because they have to pretend that it’s real and respond to the questions
being asked.’ Colleague Support
Worker
‘In that short space of time, the knowledge gained was a huge leap. The trust they showed
in us too, in asking questions that the community would ask. It was a real eye opener for me.’
Colleague Support Worker
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Step 9 Conduct a service familiarisation visit with peer educators
If relevant to the cancer prevention activity, the service familiarisation visit is an important step following the training day. It gives peer educators the opportunity to connect with a local health provider. This way, peer educators establish direct links with the cancer prevention service system: for example, the community health service where the community health nurse does Pap tests or the local BreastScreen service.* Peer educators can then share information about these services with those attending their upcoming peer-to-peer sessions.
In Cancer Council Victoria’s experience, the service familiarisation visit has another important benefit too. It gives peer educators who have never screened or are under-screened the opportunity to make an appointment on the spot. We have found that those who then attend appointments have yet another layer of information to share with their peers: the actual experience of the screening. We believe this first-hand experience that’s shared peer-to-peer is part of what makes the peer education approach so powerful in shifting behaviour in the desired cancer prevention direction.
* We realise that the delivery of the National Bowel Cancer Screening Program differs, in that the invitation to screen and the test itself, is sent to people’s homes. Eligible peer educators can nonetheless do the test and share the experience with others ‘in community.’
‘I worked in collaboration with the community health service to
arrange the visit. The women met me there as agreed on the training day. Women were shown the clinic
and the nurse explained what happens when she conducts a Pap
test. She showed the equipment and the rooms. Many women made appointments; we learned they had not ever had a Pap test before this.
We found that their subsequent experience held them in good stead
when it came time to explain the process to their peers.’ Program Coordinator
‘The visit was important because women can be scared. After the introduction, the nurse explained everything and made it less scary
for us. Everyone relaxed.’ Karen Peer Educator
‘We all made appointments, and the experience was good. No worries at all.
We can now introduce the nurse to other women and tell them she’s very good.’
Karen Peer Educator
ISIS Primary Care Community Health Nurse
Peer educators’ delivery
Delivery is about your trained peer educators providing peer-to-peer sessions ‘in community’ and you moving into the background but supporting them as needed.
PAGE 37
‘I’ll never forget what I learned, and told a friend how happy I was
for the opportunity. Everything was so valuable and I wanted to share it. I knew I could make a
lot of difference. Cancer is in our community, and I now know how to
prevent it.’ Karen Peer Educator
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Step 10 Allow peer educators to do their work
One of the most exciting parts of cancer prevention peer education is seeing peer educators with everything they need to do their work ‘in community’, and witnessing their transformation into peer educators. After the service familiarisation visit, you won’t see your peer educators for about two months, as they will be delivering their sessions in their communities. Specifically, they will be:
•• working in pairs to deliver two sessions to their communities, using the cancer prevention presentation they were shown and got to practice at the training day and drawing on the information they learned during the course of that day
•• recruiting at least 10 people from their community to attend each of their sessions
•• contacting you if they have questions about their presentation or the information they are sharing with their community
•• using their vouchers to cover session costs incurred (such as catering), and
•• completing their written evaluation forms.
Step 11 Provide extra support for peer educators as needed
Support for the peer educators doesn’t stop after the training day or the service familiarisation visit. You have already given the peer educators your contact details and let them know that you are available to answer any questions that they or their community might have during the course of delivering their sessions. Be true to your word and provide support if contacted by a peer educator any time over the next few months.
Peer education session delivered at home
‘I was so grateful, and was glad to learn. I had no
idea about the Pap test or why it was important. I was required to take it
when I arrived, but I didn’t know why. No one told me why. I was happy to learn why that day. And I wanted to share what I’d learned with others: my family and community.’ Karen Peer Educator
‘I have been in Australia for 7 years and have never heard of a Pap test. In my group I had people who were here for 4, 5 and 6 years who also didn’t
know about the Pap test. It was the first time they
had heard of the Pap test and the HPV vaccine and
had lots of questions. Both of us (pair of peer educators) had the Pap test before we did our
presentations and when we talk about it we say it’s not painful or shameful.’ Karen Peer Educator
‘We told others how important it is to have
the injection when young and to do the test after
marriage. Everyone listened. Our community
is interested in the knowledge. It was easy to bring them to the session.’
Karen Peer Educator
Evaluating
This part of the manual focuses on the activities that form the basis of evaluating your cancer prevention peer education initiative.
There are three steps involved: ••Methods of data collection
••Hold the evaluation meetings
••Write a final report
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Step 12 Methods of data collection
This step requires you to reconnect with the work that you completed in Step 4 Prepare a logic model (page 24). It also requires you to revisit one of the documents prepared in Step 6 Develop materials and resources (page 30): the written evaluation form.
Your logic model is a clear visual representation of the cancer prevention peer education initiative that you’re implementing. It shows the inputs, activities, outputs and desired impacts, and their relationships. Your logic model has another important purpose, now that the time has come to evaluate your work. You can use the outputs in the logic model to guide a process evaluation, and the desired changes in the logic model to guide an impact evaluation; and by doing both types of evaluation you’ll be in a position to determine the value of your endeavour.
Process evaluation relates to how your cancer prevention peer education initiative went: for instance, who was reached (or affected) by the work, their experiences in being involved, and the quality and appropriateness of the materials and resources developed.
Referring to your logic model, we suggest at a minimum that the following outputs are evaluated for the effectiveness of their processes:
•• the sessions delivered by peer educators ‘in community’
•• the materials and resources used for these sessions
•• the training day for the peer educators
•• the service familiarisation visit.
Impact evaluation relates to what your cancer prevention peer education initiative was able to change in the immediate and medium term: for instance, an increase in knowledge, skills and confidence, an improvement in linkages to parts of the cancer prevention system, or positive behavioural shifts in cancer prevention behaviour.*
Referring to your logic model, we suggest at a minimum that the following desired changes are evaluated to determine the actual impact that your initiative had.
•• Increased knowledge among peer educators of the cancer that was the focus of your initiative, and its prevention.
•• Increased confidence and skills among peer educators to share cancer prevention messages ‘in community’.
•• Improved linkages between peer educators and parts of the prevention system (especially local health/screening providers).
•• Increased screening or HPV immunisation rates among peer educators and those receiving peer-to-peer education.
•• Sustained messaging by peer educators six months after the training day.
Once you have settled on the parts of your logic model to focus your process and impact evaluation, the next thing to do is work out the best way of getting the information you need to do the evaluation. These are called methods of data collection.
*Longer-term desired changes are the focus of outcome evaluation, which we suggest lies beyond the scope of your evaluation.
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For cancer prevention peer education with hard-to-reach communities, it’s important that these methods of data collection are as unobtrusive as possible and not a burden to those who are the main source of the data: the peer educators. We advise against complex written tests that measure knowledge pre and post, for instance; and recommend well-evidenced methods that are more ‘naturalistic’ and ‘participatory’, meaning they are deeply relational, interpersonal and attuned to the ways in which peer educators themselves regard success or achievement in the context of their lives. In keeping with being as culturally competent as you can as a practitioner, this way of evaluating recognises that peer educators have a unique vantage point from which to work with them on the evaluation.
We suggest the following methods of data collection:
•• Your observations throughout your interactions with peer educators (and your documentation of your observations). This is the best method of data collection for the training day and the service familiarisation visit.
•• A first evaluation meeting, which occurs as soon as peer educators have completed their sessions (the date of which was set on the training day).
•• A final evaluation meeting six months after the training day, also co-facilitated (the date of which will need to be set).
•• The written evaluation form completed by peer educators following their peer-to-peer sessions ‘in community’ (if adequate literacy levels).
Each of these methods of data collection has the capacity to gather different types of data that are relevant to process and impact evaluation.
Your observations can collect a lot of data about:
•• increases in knowledge, skills and confidence among peer educators as a result of the training day, and
•• improved linkages between peer educators and local screening/health providers as a result of the service familiarisation visit.
You will literally see the knowledge gained and skills and confidence build as peer educators do their presentation practice runs, or you will notice how willing they are to make screening appointments during the service familiarisation visit. These observations are all relevant to impact evaluation, so make sure you write down your observations somewhere.
Your observations can also collect a lot of data about the experiences of peer educators on the training day or at the service familiarisation visit. For example, you’ll perceive their safety with one another as the training day progresses; or you may see them getting more confident using the materials and resources you’ve developed for them; or you could notice the rapport established by the local screening provider during the visit. This is all relevant to process evaluation. Again, be sure to write down your observations somewhere.
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The first evaluation meeting is to occur soon after the peer educators have delivered their sessions. This meeting can provide you with all sorts of data on:
•• how the peer-to-peer sessions were experienced by peer educators and community members alike
•• how peer educators found the training day and service familiarisation visit
•• any positive behavioural shifts that have occurred among peer educators and those who came along to their sessions
•• any difficulties or challenges encountered during the training day or peer education sessions.
To get this data, you’ll need to put specific questions to your peer educators. The answers given will be relevant to process and impact evaluation; and in the next step of this manual, we’ll see exactly how to capture them.
The final evaluation meeting is to occur six months after the session delivery. This meeting can provide you with very specific data about:
•• sustained messaging by peer educators following the training day, and
•• any further desired changes in prevention behaviour within the community.
As with the first evaluation meeting, you’ll get this data by asking peer educators questions. Once again, the answers given will be relevant to process and impact evaluation; and once again we’ll see how to capture these in the next step of this manual.
The written evaluation form can provide you very specific data about:
•• the sessions delivered by the peer educators (e.g. how many people attended, what participants liked or liked less about the information that was given, how peer educators felt about their presentations, and the helpfulness of the materials and resources)
•• the intent of peer educators to continue messaging, and
•• the intent of peer educators to make bookings with local screening providers. The answers given on the form are relevant to your process evaluation. It’s very important that you collate all completed forms, and this must be done at the first evaluation meeting.
Please see the list of the questions we put to the Karen women who were part of Cancer Council Victoria’s Cervical Cancer Prevention Peer Education program, when we convened the first and the final evaluation meetings. (See appendices on page 53 and 54)
Step 13 Hold the evaluation meetings
There are two evaluation meetings. Attendance at the first evaluation meeting is a requirement of the peer educators, and this must be clearly outlined in the roles and responsibilities as shown in the example on page 50 of this manual.
The first evaluation meeting occurs as soon as peer educators have completed their sessions, the date of which was set on the training day. We suggest three hours for this meeting, and that the co-facilitator is the same colleague who attended the training day.
•• Arrange catering and childcare (if this is needed) and confirm venue arrangements for the day. Book an appropriate interpreter from a reputable service and brief them fully about the meeting. If possible get the same interpreter used for the training day.
‘We are so busy so it was good to come back together and talk, listen
to each other, learn about how we all did our sessions. It was good to
hear that.’ Karen Peer Educator
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•• Brief your co-facilitator and decide on roles for the day. One of you needs to pose the questions while the other scribes, and you should share the load of asking questions and scribing between you.
•• It is important to understand that scribing the responses given by peer educators is the only way for you to capture their words. Be diligent in writing down what they have to say, verbatim if you can.
•• The questions you have prepared should be followed in order to get the data you need for the evaluation; but allow the peer educators to engage with one another and share experiences too. You want the conversation to flow naturally.
At some point in the meeting, you’ll need to collect the written evaluation forms that peer educators have completed and have brought with them.
The only other task that needs to be completed at this meeting is to award peer educators a certificate of appreciation and a final voucher for their participation in the initiative (refer to Resourcing requirements on page 45).
Before you wrap up, be sure to set the date of the final evaluation meeting.
The final evaluation meeting should be held at least six months after the training day, as this is the meeting that specifically collects data on the medium-term impacts of your initiative. We suggest a couple of hours for this meeting, and that the co-facilitator continues to be the same colleague as before.
Do the same preparations as above for catering, childcare, venue, interpreter and getting ready with your questions. Run the meeting in the same way: have an outline of questions you’d like answered, but allow the conversation to unfold naturally as well. Expect to hear more stories about how your inspiring peer educators are creating avenues for learning in their community, from their hearts.
‘The scribe’s role is really important. It’s when you can get the really rich qualitative
details about the experiences of the peer educators, their personal journey, and what they’ve observed in their
community. It demands your concentration and focus!’
Colleague Support Worker
TIP
It’s really important for the evaluation of your initiative that all peer educators attend the first evaluation meeting. By making this meeting the time when they receive their certificates and vouchers, you’ll give yourself the best chance of a 100% turn out!
Evaluation session Western region Evaluation session Eastern region
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Step 14 Write a final report
A final report is a great way to wrap up your initiative because it pulls together everything the peer educators have done and achieved, documents the lessons learned and insights you’ve gained to inform the next time it’s implemented, and builds the case for doing it again – with the same hard-to-reach community in a different area or a different hard-to-reach community altogether.
We suggest the following structure for your final report.
•• Acknowledgements. Thank the peer educators especially.
•• Abbreviations and acronyms.
•• About the initiative. Describe the background and context, include the goal and objectives, include the logic model, and describe the planning and implementation steps that you took.
•• Methods of data collection for the evaluation. These are observations, the first evaluation meeting, the final evaluation meeting and the written evaluation form.
•• Results of process evaluation. What you’ve observed or your peer educators have said about your initiative’s processes: who was reached, their experiences in being involved, and the quality and appropriateness of materials and resources.
•• Results of impact evaluation. What you’ve observed or your peer educators have said about changes in knowledge, skills and confidence, relationships with local screening providers, and shifts in cancer preventing behaviour; and also include evidence of sustained messaging months after the training day.
•• Discussion or conclusion. The final value you can give to the initiative based on the findings presented in the preceding two sections.
•• Recommendations. These are drawn from the achievements, lessons learned and practice insights documented throughout the report.
Keep your sections brief and to the point to be convincing. Remember to share the report within your organisation, especially to those who gave your initiative the green light; and to those within the cancer prevention sector more widely, as evidence of best practice in relation to cancer prevention peer education with hard-to-reach communities.
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References
AVIL (2006) A framework for peer education by drug-user organisations, Australian Injecting and Illicit Drug Users League, Canberra <www.aivl.org.au/resource/a-framework-for-peer-education-by-drug-user-organisations/> retrieved 13 August 2015
Drummond P, Mizan A, Brocx K and Wright B (n.d.) A peer-education model to increase sexual health knowledge in refugees from West Africa, Department of Health, Government of WA, Perth <www.public.health.wa.gov.au/cproot/2113/2/Report%20Sexual%20Health%20Knowledge%20in%20Refugees%20from%20West%20Africa%202008.pdf> retrieved 13 August 2015
ECCV (2006) Cultural competence guidelines and protocols, Ethic Communities Council of Victoria Inc., Carlton <eccv.org.au/library/doc/CulturalCompetenceGuidelinesandProtocols.pdf> retrieved 20 August 2015
Greaves L, Pederson A, Poole N (2015) Gender equity in health promotion online course Vancouver, British Columbia)
Hawe P, Degeling D and Hall J (1990) Evaluating health promotion: A health worker’s guide, MacLennan & Petty, Sydney
Solar O and Irwin A (2010) A conceptual framework for action on the determinants of health. Social determinants of health discussion paper 2, World Health Organization, Geneva <www.who.int/social_determinants/publications/9789241500852/en/> retrieved 20 August 2015
UNAIDS (1999) Peer education and HIV/AIDS: Concepts, uses and challenges, UNAIDS, Geneva <www.unaids.org/sites/default/files/media_asset/jc291-peereduc_en_0.pdf> retrieved 13 August 2015
Victorian Government Department of Human Services (2008) Integrated health promotion: A practice guide for service providers <www2.health.vic.gov.au/Api/downloadmedia/%7B85EB0DC8-F10B-4591-88E2-F294A0FC4DCE%7D> retrieved 8 March 2016
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Appendices
1. Invitation to participate, page 48
2. Expression of interest form, page 49
3. Peer educator roles and responsibilities, page 50
4. Training day invitation, page 51
5. Written evaluation form, page 52
6. First evaluation meeting, page 53
7. Final evaluation meeting, page 54
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Cancer preventionpeer education
with hard-to-reachcommunities
A practice manual
April 2016 www.cancervic.org.au www.papscreen.org.au
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